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Overview

The Trobriand Islands of Papua New Guinea have been depicted as a place of sexual freedom ever since these small atolls in the southwest Pacific were made famous by anthropologist Bronislaw Malinowski in the early twentieth century. Today in the era of the HIV/AIDS pandemic, how do Trobrianders respond to public health interventions that link their cultural practices to the risk of HIV? How do they weigh HIV prevention messages of abstinence, fidelity, and condom use against traditional sexual practices that strengthen interclan relationships in a gift economy? Written by an anthropologist who has direct ties to the Trobriands through marriage and who has been involved in Papua New Guinea's national response to the HIV epidemic since the mid-1990s, Islands of Love, Islands of Risk is an unusual insider ethnography. Katherine Lepani describes in vivid detail the cultural practices of regeneration, from the traditional dance called Wosimwaya to the elaborate exchanges that are part of the mortuary feasts called sagali. Focusing on the sexual freedom of young people, the author reveals the social value of sexual practice. By bringing cultural context and lived experience to the fore, the book addresses the failure of standardized public health programs to bridge the persistent gap between HIV awareness and prevention. The book offers insights on the interplay between global and local understandings of gender, sexuality, and disease and suggests the possibility of viewing sexuality in terms other than risk. Islands of Love, Islands of Risk illustrates the contribution of ethnographic research methodology in facilitating dialogue between different ways of knowing. As a contemporary perspective on Malinowski's classic accounts of Trobriand sexuality, the book reaffirms the Trobriands' central place in the study of anthropology.This book is the recipient of the annual Norman L. and Roselea J. Goldberg Prize for the best project in the area of medicine.

Culture and HIV in the Trobriands

Vanderbilt University Press

HIV, the human immunodeficiency virus, is a pathogen with multiple magnifications. In microscopic imagery, HIV is a patterned geometry of interlacing circles and diamonds. Carried in the cells of semen, vaginal mucosa, blood, and milk, the virus attaches to DNA helixes and assails T-cells. HIV colonizes the most basic dimensions of human experience, exploiting our fertility and sexuality while gaining velocity through social structures and processes that map multiple routes of transmission. Far greater than a microorganism, HIV looms large in the social body as it is configured by discourses of sexuality, morality, risk, fear, and death. It is uncanny how a virus with no immediately visible manifestations has the capacity to make visible the ways people know themselves and to alter that knowing.

Biomedical science has made possible an understanding of HIV pathology, how the virus damages the human immune system to the extent that infected bodies eventually die from the complications of AIDS, the acquired immune deficiency syndrome. But such knowledge has not been able to prevent the persistent spread of the virus throughout the world. Since the virus was first isolated and named in the early 1980s, the HIV epidemic gained rapid prominence as the most serious public health challenge in the contemporary world, expanding to all parts of the globe and reaching dramatic prevalence in many countries, with an estimated total of sixty million people having been infected by the virus and nearly twenty-five million deaths from HIV-related causes (UNAIDS 2010; UNAIDS and WHO 2009). This pandemic of staggering proportions has not occurred as a single global event. Rather, HIV infection proliferates into multiple epidemics within particular contexts of space and time (Mane and Aggleton 2001:23). Even as there is not one epidemic, there is not simply one virus. More accurately, complex viral strains have evolved in interaction with different biological, social, and structural environments (Hutchinson 2003; Singer and Clair 2003). The manifestations of HIV pathology are not revealed under a microscopic lens but in the way "social forces and processes come to be embodied as biological events" (Farmer 1999:14).

Concurrent with the relentless spread of the viral infection over the last three decades are multiple ways of comprehending HIV and AIDS as different knowledge and belief systems converge and interact to coproduce meaning. These conjunctions reveal how the global phenomenon is "simultaneously an epidemic of a transmissible lethal disease and an epidemic of meanings or signification" (Treichler 1999:11). Discourses of sexuality, risk, and disease influence the interpretive process of making sense of HIV and AIDS and gain currency through the public health policies and interventions that are put into place to respond to epidemics, with direct consequences for how HIV takes shape within specific contexts. Based persistently on biomedical models of disease, HIV programs infuse the language of prevention with predominantly Western assumptions and moralities about human sexuality and gender (Brummelhuis and Herdt, eds. 1995; Herdt and Lindenbaum, eds. 1992; Patton 2002; Pigg 2001b). The power of language to name and classify epidemics based on preconceived notions, and to construct categories of meaning for prescriptive responses, "is not merely symbolic, but has material outcomes that impinge on people's lives" (Seidel and Vidal 1997:59). The global migration of this discursive epidemiology (Jolly and Manderson 1997:19) potentially affects people's capacity to articulate local knowledge and form congruent links with new information to enable prevention within particular settings (see Adams and Pigg, eds. 2005:19–20).

Biomedicine, itself a cultural construction based on deeply entrenched social and historical codes (Treichler 1999:18), inextricably influences how HIV is understood and represented. Focused on the "neutral terrain of the physical body" (Lock 1988:7), the biomedical paradigm of disease causation is historically derived from Western epistemic notions about the individual as an autonomous and bounded entity of bodily elements and functions, and about sexual behavior as a naturalized human drive (see Gordon 1988; Parker 1995; and Scheper-Hughes and Lock 1987). In conjunction with this paradigm, epidemiological surveillance is used to monitor and predict HIV transmission patterns and trends by conceptually isolating sexual behavior at the individual level as an independent variable. Such methodological individualism reduces sexual acts to units of measure, disembodied from cultural meanings and lived experience (Pirkle 2009; see also Clatts 1995; Kippax and Crawford 1993; Parker 2001). Reductionism disallows that "physically identical sexual acts may have varying social significance and subjective meaning ... in different cultures and historical periods" (Vance 1991:878). Moreover, the predictive relation between individual behavior and disease occurrence is "framed in terms of risk, an epidemiological category that plucks behavior from context" (Lindenbaum 2001:378).

As a corollary to constructions of the atomized body and the risk of disease, the majority of HIV prevention strategies employ individualist models of behavior change, which situate beliefs, attitudes, and behaviors within the psychological domain of individual minds (Kippax and Crawford 1993). These models, conventionally used for predicting and modifying behavior in relation to risk, are referred to as "social-cognitive" in the health psychology literature. The "social" is generally represented as a measure of individual agency responding to various external factors, rather than the relations between different social actors, whereas the "cognitive" is represented as an internalized struggle between risk and reason. The emphasis of behavior change is on rational intention—the individual, armed with factual information, setting out to achieve goals.

Adjunct to behavior-change models are Knowledge, Attitude, and Practice (KAP) surveys, which use various quantitative methods to collect information at the population level. Such models and methodologies are regarded as useful for HIV interventions because they provide a means to make standardized comparisons and predictions about behavior change and they generate baseline data to monitor and evaluate the impact of awareness campaigns. To this end, paradoxically, evidence of behavior change tends to be measured as an outcome of the effectiveness of program implementation rather than as individuals acting on new information (see Patton 1990). Evidence for the effectiveness of HIV behavior change strategies remains shallow and elusive, with little robust indication of the relationship between increased public knowledge of HIV and a corresponding change in sexual behavior to minimize transmission (Campbell 2003; Kippax and Crawford 1993). What is apparent is that such individualist research methods and strategies result more readily in the externalization of risk, reinforcing the discourses of fear and blame that have dominated representations of AIDS as a "killer disease" since the beginning of the global epidemic (Hammar 2008; Treichler 1999).

The interventionist language of HIV prevention is steeped with metaphors of distancing (Reid 1994:1) that invite the externalization of risk, implicitly communicated in the epidemiological surveillance categories of "core transmitters," "risk groups," "risk behaviors," and "hot spots of infectivity" (Barnett and Whiteside 2002; Seidel and Vidal 1997). Such terms are conceptualized with quantifiable dimensions so that the relative probability of finding infection can be statistically measured (Barnett and Whiteside 2002:80). The terms assume an objective distance and stability from which to model risk factors and target interventions, providing "an illusory cartographic certainty in a turbulent terrain" (Jolly and Manderson 1997:20). The subtexts of moral and social deviancy invoked by categories of risk derive in part from historical representations of people marginalized from positions of power—prostitutes, homosexuals, the poor, and people of color (Kielmann 1997; Patton 1994, 2002; Treichler 1999). Information about HIV is thus encountered from various subject positions prefigured as "target groups" in need of transformative interventions (see Craddock 2000:154).

Behavior-change models that target individuals with assumptions about responsibility and choice, often in the guise of empowerment, belie the social and structural inequalities that contribute to the gendered vulnerability to HIV (Waterston 1997; Farmer 1999). They also obscure the dilemma of choice regarding biological and social reproductive roles, particularly for women, and the interrelated concerns of fertility control and disease prevention (Hammar 1998b:53). The biomedical paradigm for the prevention of mother-to-child transmission of HIV presupposes the responsibility of individual women, which exaggerates female agency and implies that ignorance of HIV infection status is morally negligent behavior (Farmer et al., eds. 1996:182). In reality, many women throughout the world, including in Papua New Guinea, are unaware of their HIV status because testing and diagnostic services are not available or accessible, or they are uninformed subjects of antenatal surveillance in the service of producing unlinked statistical data on prevalence for the purpose of "evidence-based" HIV programming.

Whether utilizing tropes of risk or empowerment, the language of HIV prevention persistently aligns sex with deviance, disease, and death, while largely ignoring the dimensions of sexual desire, consensus, and pleasure. Such dystopic representations of sexuality pervade the standardized HIV awareness and prevention strategies pitched at individual behavior change that are promoted by international agencies involved in the global AIDS response and implemented by country programs of response (Barnett and Parkhurst 2005; Eves and Butt 2008:7–8). The standard ABC prevention model (Abstain, Be faithful, use Condoms) frames sexuality in terms of risk and promiscuity in an implied moral hierarchy of behavior change, where "abstinence" and "being faithful" are preferable to condom use. Promoting condoms as protection in this lethal layering of signification reinforces a negative association between condoms, infidelity, and the spread of disease, so that protected sex is deemed morally bad and risky, while unprotected sex is held to be morally good and safe and is assumed within marriage and other intimate relationships (Hammar 1998b; Smith 2009:106). Condoms are thus inscribed with risk and danger, their use symbolizing and augmenting distrust in sexual relationships rather than negotiated consent (Bujra 2000; Sobo 1995).

The "globally circulating template" for HIV awareness (Pigg 200ia:i03), preoccupied with conveying factual and consistent information about HIV while inscribing subtexts of deviance about sexual behavior, limits the application of contextual knowledge and experience that reflects the complexities and particularities of local epidemics (Treichler 1999:153). Typically, awareness sessions are held as perfunctory one-off events, and messages are delivered by rote with little or no reference to cultural meanings and lived experience. While people may readily internalize the "basic facts" about HIV, the information holds "a range of doubts, qualifications, contradictions and uncertainties, which ... blunt the factual messages imparted" (Campbell 2003:25). The communication process seldom allows space for resolving questions that arise and for making links with social practices.

The importance of facilitating awareness about HIV and the social and structural factors that contribute to HIV susceptibility must not be underestimated for places like the Trobriands—and places elsewhere in Papua New Guinea and the wider Pacific region—where the capacity and resources to provide counseling, testing, and clinical treatments remain limited, and where even condoms are not widely available, accessible, or acceptable. HIV communication strategies informed by the dynamics of place are more likely to inspire active involvement of people and communities in prevention efforts. Whether by mass media campaigns, social marketing, or interpersonal dialogue, effective communication for prevention requires an engagement of the imagination across a vast field of cultural meanings and social practice.

HIV and Culture

The Pacific Regional Strategy on HIV/AIDS acknowledges the challenge to develop a program of response that "feels and smells like the Pacific," representing the region's "diverse cultures and religious backgrounds, and differing national HIV epidemics" (Secretariat of the Pacific Community 2005:11). While the sensory idiom may be just a respectful gesture toward diversity, it nonetheless inspires and legitimates approaches that respect cultural ways of knowing and being. Rather than simply replicating global blueprints for policies and programs designed from an outside perspective, the rhetorical ethos of the strategy encourages organic understandings of local realities as the foundation for an effective response. Appeals to cultural specificity are prominent in the Pacific, where often traditions are asserted to negotiate emerging identities and issues (Jolly 2005; Jolly and Thomas, eds. 1992; White and Lindstrom, eds. 1993). The notion of place, with its "naturalized association" with culture, operates as a key orientation for social interaction and expresses genealogical affiliation and moral location (Gupta and Ferguson 1992:7; see also Rodman 1992:646).

The importance of place in the production of knowledge invites a closer consideration of how culture is conceptualized in the language of HIV, particularly as an epidemiological variable of risk. In the mid-1990s, the awareness message "HIV/ AIDS does not respect tradition, culture, or religion" was translated into several Pacific languages on posters produced by the Secretariat of the Pacific Community to underscore the region's collective vulnerability to the impending epidemic (United Nations 1996:73, 79). The maxim quickly took hold and is recited frequently in HIV training workshops and awareness sessions in Papua New Guinea and reproduced on T-shirts and hand-drawn posters (see Figure 1.1). This rhetorical discord between culture and HIV is apparent also in the familiar assertion that "cultural taboos" do not allow open talk about sex (hence, culture negates the problem of HIV), commonly expressed in the Trobriands and many places throughout Papua New Guinea and the Pacific (Gibbs and Mondu 2010; Vete 1995).

The polarity drawn here between Pacific cultures and HIV indicates a strong sense of place and a stable, rooted belonging threatened by an intrusive foreign pathogen. On the contrary, the concept of culture in the biomedical paradigm converts places of belonging into sites of the exotic "other." The global discourse of HIV persistently renders culture as a bounded and static impediment to development and behavior change. "Culture" thus easily becomes a quantifiable epidemiological variable of "risk" and disease causality (Brummelhuis and Herdt, eds. 1995; Setel 1999). Such use of the culture concept also reinforces biological explanations of sexuality in terms of instincts and corporeal essences based on essentialist assumptions about the individuated person (Jolly and Manderson 1997:1; see also Vance 1991:880). This "etiologization" of culture (Wardlow 2002:153, 154) obscures social and historical processes and the structural inequalities that produce HIV vulnerabilities, and it has the potential to thwart HIV communication by representing culture—and cultural constructions of sexuality—as pathological and in need of remedial intervention. Racial constructs of difference fold easily into notions of cultural pathology and the discordant binary between "us" and "them." Eileen Stillwaggon observes, "Persistent notions of racial difference suffused the social science literature on AIDS in Africa, especially in the first fifteen years of the epidemic. No one used the word 'race,' but it entered into the discourse as 'culture'" (2003:811–12; see also Schoepf 1995).

The totalizing view of culture perhaps is linked to seeing the spread of HIV as a singular event that manifests everywhere the same way or, at any rate, requires interventions based on standardized international best practices (UNAIDS 1999). From the initial years of the global response to the epidemic, the power of HIV to transcend borders and cultures produced an urgency to respond uniformly. In Culture and Sexual Risk, one of the first publications to examine the phenomenon of AIDS from an anthropological perspective, the authors observe how the epidemic "imposed upon anthropology its totalism and global effects, shattering our prior particularistic conceptions of culture and society" (Brummelhuis and Herdt 1995:xii). The gradual incorporation of culture into HIV policy and program responses largely reflects the growing contribution of anthropological research to a richer understanding of localized epidemics and the cultural constructions of sexuality, gender, and disease (Farmer 1997; Herdt 1992; Jenkins 2002; Parker 2001; Schoepf 2001). Ironically, the application of the culture concept in relation to HIV seldom draws on the vigorous theoretical critique of culture within the discipline of anthropology, revealing the uneasy epistemic relations between the fields of anthropology and epidemiology (Adams and Pigg, eds. 2005; Herring and Swedlund, eds. 2010; Trostle 2005).